Mr. A-, middle-aged, who had been ailing for a year, and had. had stomach symptoms for three months and a noticeable tumour for six weeks, was supposed to be too ill and anaemic for operation, but as the tumour which was situated in the left hypochondrium and epigastrium was freely movable I decided to operate. On May 23rd, 1902, I found a mass of cancer involving' the centre of the stomach, which I removed along with some glands adjoining it. Recovery was uninterrupted. A letter dated January 22nd, 1903, from Dr. M-, states: "Patient very Avell, has gained 14 lb. in weight. No evidence of return of growth. Able to transact his business." The patient lived until 1905, when he had recurrence of the disease and died some months later.
In 1902 I reported a case in extenso where I had removed the whole of the stomach, except a small portion of the dome adjoining the oesophagus, for malignant disease on March 18th, 1901. I am glad to say that this patient, over six years later, remains in absolutely good health • he has a good appetite, enjoys his food, and is able to attend to his business as usual. The following are notes of the case :
Mr. -, aged thirty-eight years, was sent to me on March 18th, 1901, by Dr. R. O. Petrie, with the following history :
He had since childhood always complained of flatulence and had suffered from indigestion, though he had only been ill for two years, during which time he had suffered from fatigue, with some loss of strength but no pain. Six months ago he began to have pain every morning, which started in the epigastrium and passed over to the right side of the abdomen. There was no pain immediately after food, but it always came on before the next meal, when food gave relief. He vomited for the first time the week before seeing me. At that time he had an attack of diarrhoea which was thought to be due to a chill. He had never been constipated. There had been great loss of flesh during the past twelve months, amounting to 2 st., his weight when seeing me being 9 st. 1 lb. He looked ill and cachectic. He was quite sure that he had never vomited blood and that he had never seen blood on the motions.
On examining the abdomen a tumour could be easily seen and felt, occupying the epigastric region, and extending from the left costal margin nearly as far as the right. On distending the stomach with air the tumour was pushed downwards, but there did not seem to be much dilatation. The tumour had a wide range of mobility, could be made to pass to the right and left side of the abdomen, and could be pushed up under cover of the liver and down below the margin of the ribs. During manipulation the tumour hardened under the hand, when it was very distinct, but when the stomach muscle was relaxed the growth was less prominent. There was no free HCl in the stomach contents. An operation was proposed and consented to, and in the presence of Dr. Petrie I opened the abdomen by an incision through the right rectus. The tumour at once came into view, and proved to be a firm, nodular, malignant growth involving nearly the whole of the stomach from the pylorus to the oesophagus, the only portion of the organ apparently free being a little of the dome near the left of the oesophageal opening. There was no ascites, and no enlarged glands could be felt, nor could any secondary growths be seen.
As it was clearly useless to perform any lesser operation, and as the tumour was so mobile, gastrectomy was decided on.
The duodenum an inch beyond the pylorus was clamped by long forceps covered with rubber tubing, the lesser and then the greater omenta were divided between ligatures, and as there were no adhesions the large tumour was then drawn down, and the oesophagus and dome of the stomach were clamped by two forceps applied from the left and right side respectively. The stomach was then cut away by scissors, and after all visible vessels had been ligatured the clamps were released and a few other bleeding points taken up; but throughout very little blood was lost. The duodenum was brought across the spine and fixed by an external celluloid thread and an internal catgut suture around a decalcified bone bobbin to the margin of the stomach remaining around the oesophageal opening. The duodenum and cardiac end of the stomach seemed to hold together with very little tension. The operation had been effected without soiling the peritoneal cavity, as the parts had been isolated throughout by sterilised gauze. The abdomen was closed in layers by means of continuous catgut sutures, and the patient was returned to bed in very good condition.
He was allowed to take a little liquid nourishment with plasmon after twenty-four hours, and, after a week, light custard pudding. Nourishment of more consistency was then given, and within the month he was taking minced meat and other ordinary foods. A breaking-down hamiatoma at the week end delayed healing for a fortnight, but otherwise recovery was uninterrupted, and he was able to return home before the end of April.
On August 27th I received a letter from Dr. Petrie to say : " Mr. - continues well; I saw him to-day and he has become considerably stouter."
In November, 1901, he called to see me, and I failed to recognise him : he looked healthy and fat, and seemed to be vigorous and well. He had gained 2 st. in weight. He said that his digestion was very good if he did not attempt too large a meal. He gave the following as his ordinary diet chart.
7 a.m.-Breakfast cup of boiled milk and one table-spoonful of brandy.
Breakfast.-One egg boiled, or a little bacon, bread and butter, one cup of tea.
11 a.m.-Breakfast cup of boiled milk with one table-spoonful of plasmon.
Dinner.-Varying as follows : Lean of a mutton chop, little fish, chicken, or pigeon, with a little cauliflower and bread, always milk pudding, chiefly rice.
3 p.m.-Breakfast cup of boiled milk and one tea-spoonful of plasmon.